Transplant Flashcards
Indications for renal transplant
Longer survival Better quality of life Lack of exposure to dialysis complications Improved fertility Cheaper than dialysis
transplant requires
Available kidney Compatible (abo, mhc, etc) An operation Anti-rejection medication Acceptance of risk and complications Management of risks and complications
Sources of kidneys
Living donors is an elective procedure
Matching scheme for deceased donors allocates organs at short notice
Better outcomes if reimplanted in
The surgery itself
Preparation of the kidney (removing the blood)
Retroperitoneal approach to the iliac vessels
Vascular anastomoses
Ureteric anastomosis
Repair wounds
-Using hockey-stick incision in right iliac fossa
Outcomes
Most leave the hospital within 10 days
Regular appointments every 3 month
This mortality is highest within the first month, then life quality increases greatly thereafter
There are issues however in most cases
Early complications
Death (1%) and major medical complications (5%)
Bleeding (5%)
Hyperacute rejection (v.rare) Thrombosis (2%)
Haematoma/wound infection (5-10%)
Ureteric leak (1-2%) – shown on scan: contrast outside the ureter indicates a leak
Problems in the 1st year
Delayed Graft Function (DGF) -
Acute rejection - temporary inflammatory condition completely treatable
Immunosuppressive side effects
Infections - opportunistic infections (pnuemonia)
Delayed graft function
Risk factors and
The initial kidney response, perfused but do not produce urine
Equivalent to ATN of native kidney Need dialysis
BAD for kidney
decreased survival and more likely to reject
Risk factorsfor DGF
- donor age,
- blood pressure,
- length of time on ice
- levels of MHC antibodies
Acute (immunological) rejection
Destroys all but identical without drugs/modulation
Attack on graft tissue by T cells, atnibodies and eery other component of the immune system
BAD for the kidneys long term outlook
On Biopsy - Agreesive lymphocyte in the tubules more than the glomerulus
Assessing outcomes of kidney transplant
Assessing outcomes of kidney transplant Using surrogate end point, short term measures as a surrogate for long term studied using DGF, rejection and 1 yr creatinine
Assessing interventions by their effect on Patient and graft survival requires long, expensive and impractical studies
Outcome measures:
- “Hard” end Points: Patient Survival, Graft Survival
- “Soft” end Points: Acute rejection rate, 1 year Creatinine, Incidence of DGF, % CNI free
Immunosuppresive agents
General: Steroids Calcineurin inhibitors (Cyclosporine, Tacrolimus), Antiproliferative Azathioprine Mycphenolate mofetil (MMF), mTOR inhibitors (Sirolimus, Everolimus) Co-stimulation blockers (Belatacept) Induction agents: Basiliximab, Thymoglobulin etc
Experimental agents: Biologics, Daclizumab
Regimes- normally begin with everything then remove agents, use the biological therapies for pre surgery induction
Can also use: monotherapy, dual therapy and triple therapy
GOLD STANDARD immunosuppresive regimen
Low dose tacrolimuz, steroids, MMF, and induction
Immunosuppresive side effects
Toxicity/therapeutic monitoring
Steroids-many
Aza-leucopenia
Cyclosporine- hypertension, nephrotoxic, tremor
Mmf-gi upset
Tac-diabetes
Late complications
Generally increased infections
Higher incidence of malignancy
lymphoma
Skin tumours
Post-transplant lymphoproliferative disorder
Transmitted diseases
Surgical complications
Ureteric stricture
Renal artery stenosis
herniae
